Insurance not covering an annual check-up
February 24, 2020 4:03 PM Subscribe
I had my first primary care doctor visit in awhile last April, a routine new patient wellness visit, which is supposed to be 100% covered under my ACA plan. After a bizarre issue with the initial billing in December, I've now received a partially-uncovered $500 bill for the visit despite everything being in-network. Is this at all normal, and if so what's the best strategy for getting this number way the heck down?
I thought I was being a Responsible Adult scheduling this doctor's appointment -- no outstanding health issues, just wanted a routine check-up, did my research, found a good in-network doctor. All indications were that I shouldn't expect any bills from what was just a blood draw, urinalysis, and a 20-minute poke-and-chat with the doctor:
- The ACA mandates insurance plans cover one free annual wellness visit, including preventive tests and screenings
- My plan (BCBS via the ACA individual market) requires an initial visit with a primary care physician anyway to be eligible for any other benefits
- According to the statement of benefits, my plan is supposed to cover in-network preventive care, screening, and blood work at "no charge/no deductible"
- The doctor's office is in-network
- The lab used (the local hospital) is also in-network
- The visit was a standard new-patient wellness appointment with no pre-existing complaints and that turned up no extraneous issues
For some inexplicable reason, the initial bill for this was sent -- eight months after the fact -- to a parent living out-of-state, who has had zero involvement with either this doctor or my insurance plan. After a few calls to the doctor's office and the hospital, they apologetically straightened out the billing info and that was apparently that.
But now I've got an email notification from BCBS that while the office visit itself has finally been covered, there are six different charges from the local hospital for various tests -- all but one uncovered -- for a grand total of around $500:
- comprehensive metabolic panel (~$170)
- lipid panel (the only one covered, negotiated from $90 down to $10)
- urinalysis ($50+)
- free thyroxine (~$80)
- TSH (~$100)
- CBC/automated/WBC (~$100)
All tests were coded for "LAB - WELLNESS", which, again, both the ACA and my plan claim to cover.
My questions:
- Are these tests expected for a wellness visit, and if not is it normal for a doctor's office to tack them on unasked?
- Is there a reason these wouldn't be counted as preventive/screening/blood work by my insurance?
- Who should I contact about this? Doctor's office? Hospital? Insurance? All of the above?
- Any good strategies for bringing this number down if it's not some kind of mistake? Could the 90% discount the insurer secured for themselves on that lipid panel be a good guide?
- Would the initial botched billing and very protracted notification process give me any leverage in negotiating down? I've seen references to timely filing limits -- might the entire thing be wiped if they took too long to bill for it (not to mention billed the wrong person)?
- Speaking of protracted, how worried should I be about this being sent to collections, impacting my credit score, etc.? The original visit was last April.
Any advice or experiences with the godawful American insurance system would be much appreciated!
I thought I was being a Responsible Adult scheduling this doctor's appointment -- no outstanding health issues, just wanted a routine check-up, did my research, found a good in-network doctor. All indications were that I shouldn't expect any bills from what was just a blood draw, urinalysis, and a 20-minute poke-and-chat with the doctor:
- The ACA mandates insurance plans cover one free annual wellness visit, including preventive tests and screenings
- My plan (BCBS via the ACA individual market) requires an initial visit with a primary care physician anyway to be eligible for any other benefits
- According to the statement of benefits, my plan is supposed to cover in-network preventive care, screening, and blood work at "no charge/no deductible"
- The doctor's office is in-network
- The lab used (the local hospital) is also in-network
- The visit was a standard new-patient wellness appointment with no pre-existing complaints and that turned up no extraneous issues
For some inexplicable reason, the initial bill for this was sent -- eight months after the fact -- to a parent living out-of-state, who has had zero involvement with either this doctor or my insurance plan. After a few calls to the doctor's office and the hospital, they apologetically straightened out the billing info and that was apparently that.
But now I've got an email notification from BCBS that while the office visit itself has finally been covered, there are six different charges from the local hospital for various tests -- all but one uncovered -- for a grand total of around $500:
- comprehensive metabolic panel (~$170)
- lipid panel (the only one covered, negotiated from $90 down to $10)
- urinalysis ($50+)
- free thyroxine (~$80)
- TSH (~$100)
- CBC/automated/WBC (~$100)
All tests were coded for "LAB - WELLNESS", which, again, both the ACA and my plan claim to cover.
My questions:
- Are these tests expected for a wellness visit, and if not is it normal for a doctor's office to tack them on unasked?
- Is there a reason these wouldn't be counted as preventive/screening/blood work by my insurance?
- Who should I contact about this? Doctor's office? Hospital? Insurance? All of the above?
- Any good strategies for bringing this number down if it's not some kind of mistake? Could the 90% discount the insurer secured for themselves on that lipid panel be a good guide?
- Would the initial botched billing and very protracted notification process give me any leverage in negotiating down? I've seen references to timely filing limits -- might the entire thing be wiped if they took too long to bill for it (not to mention billed the wrong person)?
- Speaking of protracted, how worried should I be about this being sent to collections, impacting my credit score, etc.? The original visit was last April.
Any advice or experiences with the godawful American insurance system would be much appreciated!
I have had wellness visits coded as not free because I brought up health concerns. Apparently it was only free if I was healthy or the doctor brought up issues, not me.
I don't know if that's the case here, though.
posted by Ms Vegetable at 4:56 PM on February 24, 2020 [3 favorites]
I don't know if that's the case here, though.
posted by Ms Vegetable at 4:56 PM on February 24, 2020 [3 favorites]
I wouldn't worry about it being sent to collections for a while yet - the provider (hospital/doctor) will most likely try to call you first.
I would call BCBS if I were you. I wouldn't be enthusiastic about calling BCBS, but it's probably your best starting point. And if the first person isn't helpful, call back and try again with someone else.
posted by mskyle at 5:01 PM on February 24, 2020
I would call BCBS if I were you. I wouldn't be enthusiastic about calling BCBS, but it's probably your best starting point. And if the first person isn't helpful, call back and try again with someone else.
posted by mskyle at 5:01 PM on February 24, 2020
Is there any chance your BCBS is in a contract dispute with the hospital over being in-network? You might find mentions of this in your local press (like this). They quite often use patients as leverage in contract negotiations.
posted by sallybrown at 5:22 PM on February 24, 2020
posted by sallybrown at 5:22 PM on February 24, 2020
When these sorts of things have happened to me, I have called the insurance company first. In a few cases, I was told "y'know, you're absolutely right that this should have no copay and I'll take care of it". Other times, they told me the doctor's office had coded the visit incorrectly and a simple call to his staff got it fixed right away. Although, now that I think about it, there was one time when I had to figure out the hospital CEO's email so I could send him an email before the problem was fixed, and even then it took four months. IME, the right tone to strike in these calls is that you're looking for an ally/champion in trying to right something that is tragically and incorrectly wrong through no (apparent) fault of your own.
posted by DrGail at 5:22 PM on February 24, 2020 [3 favorites]
posted by DrGail at 5:22 PM on February 24, 2020 [3 favorites]
Response by poster: telegraph, I got an emailed EOB notice from Blue Cross back on February 7th (only just now noticed it). Logging into their site shows the partially covered items as well as the $500 owed to the hospital, including the boilerplate "THIS IS NOT A BILL." Although, the uncovered charges are footnoted with "THE CLAIM WE RECEIVED DOES NOT INDICATE THIS SERVICE WAS PROVIDED FOR TREATMENT OF AN ILLNESS OR INJURY AND THEREFORE, WOULD NOT BE COVERED BY YOUR BLUE CROSS AND BLUE SHIELD PLAN. IF THIS SERVICE WAS RELATED TO AN ILLNESS OR INJURY, PLEASE RETURN THIS CLAIM REPORT WITH A LETTER FROM YOUR DOCTOR WHICH INDICATES THE PATIENT'S ILLNESS," which doesn't sound great.
Haven't heard anything from the hospital itself yet, and honestly given their bungled communication till now I'm wondering if I'll ever hear from them without contacting them myself.
posted by Rhaomi at 6:43 PM on February 24, 2020
Haven't heard anything from the hospital itself yet, and honestly given their bungled communication till now I'm wondering if I'll ever hear from them without contacting them myself.
posted by Rhaomi at 6:43 PM on February 24, 2020
Are these tests expected for a wellness visit, and if not is it normal for a doctor's office to tack them on unasked?
The thyroid tests are the only ones I'd say maybe not a part of a annual physical but I can't say for sure since I was diagnosed with thyroid issues a few years ago and ever yearly exam has included all of these.
I wonder if because of the weird time frame on billing this, the insurance company thinks you tried to get a second annual exam in one calendar year.
posted by 922257033c4a0f3cecdbd819a46d626999d1af4a at 6:49 PM on February 24, 2020
The thyroid tests are the only ones I'd say maybe not a part of a annual physical but I can't say for sure since I was diagnosed with thyroid issues a few years ago and ever yearly exam has included all of these.
I wonder if because of the weird time frame on billing this, the insurance company thinks you tried to get a second annual exam in one calendar year.
posted by 922257033c4a0f3cecdbd819a46d626999d1af4a at 6:49 PM on February 24, 2020
Any advice or experiences with the godawful American insurance system would be much appreciated!
Honestly I just ignore everything (well, I mean, I open pieces of mail and read them, then I file them under "Medical" in my home filing cabinet) until I get a piece of paper in the mail that clearly states "THIS IS A BILL" from whoever. The whole system is so tangled and convoluted and has so many different offices and moving parts and people and policies that there's no point worrying about what you might owe before someone actually directly tells you "This is what you owe." (And I wait for a snail mail bill because IME they don't really consider you "billed" and start the clock on you needing to pay until the actual paper has gone out. So far no-one has even seemed to notice, even though I sometimes get emails and can log onto a website to see "billing statements" long before I get the actual bill.)
If I think the cost is confusingly or alarmingly high for *Incomprehensible Reasons* the first thing I do is call my doctor's office. YMMV, of course, but at least a couple of times the staff in my PCP's office have gone, "Hmmmm . . . Oh I see, that procedure got coded as "Foo" when it should/could have been coded as "Bar" . . . hang on, let me change that . . . OK, now wait for the new EOB and then wait even longer for the Actual Bill." (IOW, there are folks definitely willing and able to game the system for their patient's benefit, it can't hurt to gently inquire about this.)
If I still don't think the bill is accurate I call - on the phone and talk to an actual real live person - my insurance company and start discussing whether whatever tests/procedures I am being billed for are supposed to be covered. There's a good chance there's another mixup between the lab/hospital and the insurance company.
Then after that I look at who I'm supposed to actually pay and talk to them about payment plans if I don't have the actual cash on hand to pay the bill in full. No-one has refused to negotiate a payment plan yet.
And every single person I've contacted about this kind of thing has treated all of this as completely normal - they spend their entire working lives dealing with this morass of negotiations and snafus and confusions and miscommunication. Took 8 months to get the bill? Oh sure, that happens all the time. Bill got sent to a parent in another state? Yup, no surprise, of course it did. A guy looking to get a few more bucks knocked off a $500 bill is "easy mode" for them, AFAICT. You're definitely not some kind of outrageous outlier who's destroying their finely-tuned system and probably scamming them to boot - you're a regular Joe with a minor problem that they deal with all the time. They probably had a dozen more difficult cases before lunch.
TL:DR - wait until you get something that is clearly and plainly a "This is what you owe bill" and then if you think you should not be billed for those things start contacting people on the phone and asking why they're not covered. As DrGail says, "the right tone to strike in these calls is that you're looking for an ally/champion in trying to right something that is tragically and incorrectly wrong through no (apparent) fault of your own." (Because it's TRUE and they know it.)
posted by soundguy99 at 8:22 PM on February 24, 2020 [7 favorites]
Honestly I just ignore everything (well, I mean, I open pieces of mail and read them, then I file them under "Medical" in my home filing cabinet) until I get a piece of paper in the mail that clearly states "THIS IS A BILL" from whoever. The whole system is so tangled and convoluted and has so many different offices and moving parts and people and policies that there's no point worrying about what you might owe before someone actually directly tells you "This is what you owe." (And I wait for a snail mail bill because IME they don't really consider you "billed" and start the clock on you needing to pay until the actual paper has gone out. So far no-one has even seemed to notice, even though I sometimes get emails and can log onto a website to see "billing statements" long before I get the actual bill.)
If I think the cost is confusingly or alarmingly high for *Incomprehensible Reasons* the first thing I do is call my doctor's office. YMMV, of course, but at least a couple of times the staff in my PCP's office have gone, "Hmmmm . . . Oh I see, that procedure got coded as "Foo" when it should/could have been coded as "Bar" . . . hang on, let me change that . . . OK, now wait for the new EOB and then wait even longer for the Actual Bill." (IOW, there are folks definitely willing and able to game the system for their patient's benefit, it can't hurt to gently inquire about this.)
If I still don't think the bill is accurate I call - on the phone and talk to an actual real live person - my insurance company and start discussing whether whatever tests/procedures I am being billed for are supposed to be covered. There's a good chance there's another mixup between the lab/hospital and the insurance company.
Then after that I look at who I'm supposed to actually pay and talk to them about payment plans if I don't have the actual cash on hand to pay the bill in full. No-one has refused to negotiate a payment plan yet.
And every single person I've contacted about this kind of thing has treated all of this as completely normal - they spend their entire working lives dealing with this morass of negotiations and snafus and confusions and miscommunication. Took 8 months to get the bill? Oh sure, that happens all the time. Bill got sent to a parent in another state? Yup, no surprise, of course it did. A guy looking to get a few more bucks knocked off a $500 bill is "easy mode" for them, AFAICT. You're definitely not some kind of outrageous outlier who's destroying their finely-tuned system and probably scamming them to boot - you're a regular Joe with a minor problem that they deal with all the time. They probably had a dozen more difficult cases before lunch.
TL:DR - wait until you get something that is clearly and plainly a "This is what you owe bill" and then if you think you should not be billed for those things start contacting people on the phone and asking why they're not covered. As DrGail says, "the right tone to strike in these calls is that you're looking for an ally/champion in trying to right something that is tragically and incorrectly wrong through no (apparent) fault of your own." (Because it's TRUE and they know it.)
posted by soundguy99 at 8:22 PM on February 24, 2020 [7 favorites]
Years ago I scheduled an physical (i.e. wellness check) with a new doctor at a hospital and ended up with a bill for $300.
The insurance company told me to talk to the hospital about getting the codes on the bill corrected.
I called the number on the bill from the hospital and explained that my appointment was supposed to be a wellness check. The hospital told me they would look into it and call me back.
A few weeks later, I got a call back. They said they weren’t going to change the bill. I don’t remember if they had some reason, but I asked if I could appeal. There was a pause, and then they said they would talk to their manager and call me back.
A few weeks later, they called me back and said they weren’t going to change the bill. I asked to appeal again.
This happened maybe one or two more times before the doctor himself called me and said that he had been confused about the appointment being a wellness check and they were forgiving the bill.
So… call the number on the bill. Tell them it was a wellness check, and ask them to fix it. If they say no, ask to appeal or talk to their manager.
posted by danielparks at 8:50 PM on February 24, 2020 [1 favorite]
The insurance company told me to talk to the hospital about getting the codes on the bill corrected.
I called the number on the bill from the hospital and explained that my appointment was supposed to be a wellness check. The hospital told me they would look into it and call me back.
A few weeks later, I got a call back. They said they weren’t going to change the bill. I don’t remember if they had some reason, but I asked if I could appeal. There was a pause, and then they said they would talk to their manager and call me back.
A few weeks later, they called me back and said they weren’t going to change the bill. I asked to appeal again.
This happened maybe one or two more times before the doctor himself called me and said that he had been confused about the appointment being a wellness check and they were forgiving the bill.
So… call the number on the bill. Tell them it was a wellness check, and ask them to fix it. If they say no, ask to appeal or talk to their manager.
posted by danielparks at 8:50 PM on February 24, 2020 [1 favorite]
Best answer: The ACA's mandatory zero cost-share preventive coverage is fairly limited. For lab work, it basically encompasses screenings for cholesterol, diabetes, a few types of cancer, and STIs. Cholesterol screening being covered is why your lipid screening made it through.
Not sure which BCBS you're on, but here's a summary flyer from BCBS of North Carolina. They explicitly highlight urinalysis and thyroid testing as examples of services that aren't 100% covered preventive care.
I suspect that all your non-covered tests are not considered preventive by your insurer, and that they'll only cover diagnostic testing that's medically necessary. That aligns with your follow-up about "THE CLAIM WE RECEIVED DOES NOT INDICATE THIS SERVICE WAS PROVIDED FOR TREATMENT OF AN ILLNESS OR INJURY...." This suggests that one route you could take to reduce your costs would be to get the doctor's office to resubmit the claims with diagnosis codes that correspond to a reason to have run the tests (fatigue, etc), rather than the preventive wellness diagnosis codes they presumably used the first time. It wouldn't get the claims covered with no cost to you, but it would at least get the insurer's contracted rates applied (the 90% reduction you saw on the lipid panel).
posted by bassooner at 9:07 PM on February 24, 2020 [5 favorites]
Not sure which BCBS you're on, but here's a summary flyer from BCBS of North Carolina. They explicitly highlight urinalysis and thyroid testing as examples of services that aren't 100% covered preventive care.
I suspect that all your non-covered tests are not considered preventive by your insurer, and that they'll only cover diagnostic testing that's medically necessary. That aligns with your follow-up about "THE CLAIM WE RECEIVED DOES NOT INDICATE THIS SERVICE WAS PROVIDED FOR TREATMENT OF AN ILLNESS OR INJURY...." This suggests that one route you could take to reduce your costs would be to get the doctor's office to resubmit the claims with diagnosis codes that correspond to a reason to have run the tests (fatigue, etc), rather than the preventive wellness diagnosis codes they presumably used the first time. It wouldn't get the claims covered with no cost to you, but it would at least get the insurer's contracted rates applied (the 90% reduction you saw on the lipid panel).
posted by bassooner at 9:07 PM on February 24, 2020 [5 favorites]
PCP here. Bassooner has it right. Unfortunately, the only one of those tests that's typically considered preventive (and therefore free) is the lipid panel. The other ones are common, but not screening (meaning that everyone in a certain age range should get them).
If you had any symptoms during the visit or you have any health problems, you may be able to get your doctor's office to recode these using those diagnoses. Although it's been long enough that the insurance may push back on a recode.
posted by The Elusive Architeuthis at 10:05 PM on February 24, 2020
If you had any symptoms during the visit or you have any health problems, you may be able to get your doctor's office to recode these using those diagnoses. Although it's been long enough that the insurance may push back on a recode.
posted by The Elusive Architeuthis at 10:05 PM on February 24, 2020
Response by poster: Yeah, I think bassooner may be right -- reexamining the summary of benefits, it lists "preventive care/screening/immunizations" as "no charge/no overall deductible", but adds a side note with a link to a separate document that says this only includes specific tests. And while x-rays and blood work are likewise "no charge/no overall deductible," it also has them in the category of "diagnostic tests", which I guess only applies to stuff done for cause. So basically a wellness visit is free, and blood work is free, but blood work done as part of a wellness visit is $500? Insane. Also, my individual deductible for the plan is less than $500, so does that mean the plan doesn't cover the other tests *at all* (even if I meet the deductible) and I'm liable for the full amount?
I guess I could talk to the doctor's office first, see if they could recode as diagnostic. But I wonder if that would then cancel the coverage for the wellness visit itself (which was covered). If not, I'd definitely have to talk to the insurance next, because it seems unbelievable that something as basic as blood work at an in-network hospital would not be covered at all, not even subject to a deductible or co-pay or something. And then if all else fails I guess I could contact the hospital and see if they're willing to negotiate down to the insured rate (especially if they've already been at fault in terms of billing). Or would it be better to not say anything to anybody until I get official notice in the mail? I'm just concerned that this has fallen through the cracks again somehow on the hospital's end and they've been trying to notify me at an ancient address or something.
posted by Rhaomi at 10:59 PM on February 24, 2020 [1 favorite]
I guess I could talk to the doctor's office first, see if they could recode as diagnostic. But I wonder if that would then cancel the coverage for the wellness visit itself (which was covered). If not, I'd definitely have to talk to the insurance next, because it seems unbelievable that something as basic as blood work at an in-network hospital would not be covered at all, not even subject to a deductible or co-pay or something. And then if all else fails I guess I could contact the hospital and see if they're willing to negotiate down to the insured rate (especially if they've already been at fault in terms of billing). Or would it be better to not say anything to anybody until I get official notice in the mail? I'm just concerned that this has fallen through the cracks again somehow on the hospital's end and they've been trying to notify me at an ancient address or something.
posted by Rhaomi at 10:59 PM on February 24, 2020 [1 favorite]
It would be absolutely reasonable for you to contact the provider AND your insurance company and tell them that you haven't received a bill, merely an EOB, for service that was provided in April 2019.
posted by cooker girl at 7:04 AM on February 25, 2020
posted by cooker girl at 7:04 AM on February 25, 2020
Response by poster: Update:
Called BCBS and all they could say was it was probably a coding mistake and to have the doctor's office refile.
Called the doctor's office billing dept., relayed what BCBS said, and emailed them the EOB; they said they'd contact the hospital and get it straightened out. I mentioned my concern about collections and they said to call the hospital to let them know they were working on it.
Called the hospital billing dept. and it turned out they were still woefully out of date despite my calling them in December -- they had my parent as the guarantor and they had addresses and phone numbers on file I haven't been at for more than a decade. Looking at the billing history, they tried two defunct insurance plans before sending it to the guarantor. They'll be talking to the doctor's office about the recode.
Finally called the doctor's office billing dept. one more time to raise the possibility of them recoding the uncovered tests as diagnostic. I'll be checking back later in the week to see how it went!
posted by Rhaomi at 12:26 PM on February 25, 2020 [5 favorites]
Called BCBS and all they could say was it was probably a coding mistake and to have the doctor's office refile.
Called the doctor's office billing dept., relayed what BCBS said, and emailed them the EOB; they said they'd contact the hospital and get it straightened out. I mentioned my concern about collections and they said to call the hospital to let them know they were working on it.
Called the hospital billing dept. and it turned out they were still woefully out of date despite my calling them in December -- they had my parent as the guarantor and they had addresses and phone numbers on file I haven't been at for more than a decade. Looking at the billing history, they tried two defunct insurance plans before sending it to the guarantor. They'll be talking to the doctor's office about the recode.
Finally called the doctor's office billing dept. one more time to raise the possibility of them recoding the uncovered tests as diagnostic. I'll be checking back later in the week to see how it went!
posted by Rhaomi at 12:26 PM on February 25, 2020 [5 favorites]
Response by poster: Final update (better late than never):
The doctor's office couldn't recode it, and insurance wouldn't reconsider it. I called the hospital about possibly waiving the bill given the circumstances. At first they tried to talk me into a one-time discount ($100 off IIRC), but I persisted and finally got the whole thing cancelled after submitting some financial information. YMMV.
Frustratingly, this whole process took so long that I went in for the following annual check-up around this time. Despite scouring last year's statement of benefits and making sure to only request the bloodwork that had been covered, I still got a bill for ~$30 -- apparently even some of the tests that are covered are only covered semi-annually. Luckily the doctor's office did not end up billing me for what the insurance didn't cover, but still -- if I wasn't for M4A before, I definitely would be now.
posted by Rhaomi at 3:09 PM on July 11, 2020
The doctor's office couldn't recode it, and insurance wouldn't reconsider it. I called the hospital about possibly waiving the bill given the circumstances. At first they tried to talk me into a one-time discount ($100 off IIRC), but I persisted and finally got the whole thing cancelled after submitting some financial information. YMMV.
Frustratingly, this whole process took so long that I went in for the following annual check-up around this time. Despite scouring last year's statement of benefits and making sure to only request the bloodwork that had been covered, I still got a bill for ~$30 -- apparently even some of the tests that are covered are only covered semi-annually. Luckily the doctor's office did not end up billing me for what the insurance didn't cover, but still -- if I wasn't for M4A before, I definitely would be now.
posted by Rhaomi at 3:09 PM on July 11, 2020
This thread is closed to new comments.
If you have a bill (and not just EOB from the insurer), from what you've described, this is definitely a billing error. Doctors may quibble about whether you really needed a CBC this year or not (for example), but this is all entirely within the realm of standard practice for a wellness visit.
It is impossible for you to know at this point whether the error was made on the part of the doctor's office/hospital/lab or the insurance company. I recommend calling the insurance company and speaking to a human.
posted by telegraph at 4:22 PM on February 24, 2020 [6 favorites]